Computer-Based Training: Understanding the Elements of Good Instructional Design

Maintaining prehospital EMS certification requires that EMTs complete a minimum number of continuing education credits biennially, in a variety of applicable topics. Employers have typically provided these hours through didactic classroom lectures or structured recertification courses at local junior colleges. Yet, as budgets become increasingly tighter, many EMS organizations are looking toward nontraditional methods of instruction, such as computer-based or Internet-based training, for meeting the continuing education needs of their employees.

When looking at computer-based training (CBT) programs, it becomes obvious that not all systems are created equal. Poorly designed software may offer nothing more than screen after screen of text, where students have no opportunities to interact with the computer. Programs like this do nothing to stimulate learning and may cause students to lose interest in the training. Therefore, when considering CBT, it is essential that EMS educators, training program managers, instructors and agency administrators evaluate software for instructional design elements that motivate adults to learn, build critical thinking and decision-making skills, and impart the necessary knowledge to prepare members for recertification.

Consequences of Learner Choices

How well a training program is designed may affect the choices an individual makes regarding the use of the CBT program. Poorly designed software can result in negative behaviors such as avoidance, decreased attention levels or attempts to short cut the training process. Learner choices are decisions regarding the level and focus of effort exerted during a learning opportunity. These choices are manifest in how the learner decides to use the system (behavior) and in what the learner is thinking about while working on the system (cognition).1 For instance, an EMT working on the recertification modules may decide to watch television rather than pay attention to a video presentation. This behavior serves to reduce the amount of knowledge accrued, rendering the CBT instruc­tional format ineffective.

Many authors tout the ability of CBT to provide individualized learning, greater opportunities to practice acquired knowledge or skills, and longer time on-task as some of the strengths of CBT over other methods of instruction.1–3 However, this does not mean that trainees will exercise control over their learning wisely. Learners may choose to skip over optional practice opportunities that are critical to enhancing understanding and knowledge retention. They may also choose to move quickly through the material in an effort to return to work obligations or more enjoyable recreational activities.

Cognitive effort is also an important part of learning. Gaining knowledge requires deliberate practice, one aspect of which is focusing on the task of learning.4 A student who pays attention to the material being presented and takes advantage of optional practice activities will become more proficient than one whose attention wanders. Therefore, it is important for program designers to add elements that grab users’ attention and challenge them to learn.

Motivating to Learn

Effective CBT software needs to contain elements that conform to how adults learn, thereby sparking their interest in the lessons, holding their attention and aiding them in retaining and recalling the newly acquired knowledge. Motivation is often an overlooked aspect of instructional design, yet may be the most critical for successful implementation. Without proper motivation to learn, knowledge retention is unlikely. Good CBT programs contain elements that create a deeper motivation for trainees to use the system to its full potential. This ensures that trainees will learn the material and, perhaps most important, enable them to transfer what they learned to the job.

The foundation for motivating adults in a CBT environment is understanding the characteristics of the adult learner. The principles of adult learning, called andragogy, are highly relevant to CBT. Program designers and administrators should be aware of these principles, since they can be used to increase the effectiveness of CBT software. These principles can be applied to any form of adult learning and have been used extensively in the design of organizational training programs.

Malcolm Knowles is noted for his work on the theory of andragogy,5 which holds a number of basic assumptions about adult learning that should be considered and addressed in curriculum development. The most important elements include:

1. Inform adult learners why what they are learning is important. Adults experience a need to learn in order to cope with real-life tasks or problems.6 They want to know that what they are learning is relevant to their immediate needs and goals. It is important that lessons directly relate to the certification exam, the agency’s policies and procedures, and current prehospital practices. Learners who believe that CBT lessons are relevant to their success on the certification test and in the field will be motivated to be attentive to lessons and take advantage of optional training opportunities.

2. Allow learners to direct themselves through the information. Generally, adults are self-directed learners who prefer to take responsibility for their own learning. CBT programs should provide maximum flexibility in learning options that allow users to tailor their experience to meet the needs of their own learning style. Of course, not all adults are self-directed learners. Therefore, it is important that programs provide short, directed tasks that provide a concrete learning experience so these learners see the relevance of CBT.6

3. Use a problem-solving approach when designing lessons for adults. Adults learn best through problem-solving, and EMS is about solving problems. We evaluate patients, identify their problems and begin appropriate treatment in order to stabilize those problems. CBT programs are most effective if they use real-life examples and scenarios that EMTs may encounter on the job and develop problem-solving skills that help them do their jobs better.

4. Relate information in the lesson to prior experiences. Adults bring with them a wealth of learning and work experiences. CBT lessons should include EMS scenarios, case studies and reflective activities that facilitate use of the learner’s prior knowledge.

Good Instructional Design

Those of us who are old enough to remember the old black computer screens with lime-green text will attest to how boring it made computers, not to mention how tired it made your eyes. Today’s computer-savvy users have come to expect much more in terms of interaction, entertainment and “glitz.” But computer-based learning involves much more than “flash” and eye-popping “pizzazz”: It requires a solid foundation in the elements of good instructional design.

Robert Gagne is considered to be among the foremost researchers in the field of instructional design and training. His systematic approach to instruction focuses on outcomes or behaviors that result from training. Gagne describes a nine-step process that correlates to and addresses the conditions of learning.4,7,8 As one component of evaluating CBT software for quality, look to see if it contains this sequence of events:

• Gains users’ attention. Anyone who has been in a classroom understands that you cannot instill knowledge into a student who has fallen asleep on his desk. Likewise, CBT will fail if the learner ignores the ongoing computerized lesson in favor of watching a ballgame on ESPN. Learning cannot take place if the trainee’s attention is not captured and maintained. A quality program gains users’ attention through an engaging sequence or by posing a thought-provoking question at the onset of each lesson. Curiosity can be a good tool to motivate students to learn.

• Clearly states learning objectives. Take a look at any good EMS textbook and you will find learning objectives clearly stated at the beginning of each chapter. Placing learning objectives at the front end of each lesson gives the students an understanding of what they are expected to accomplish and allows them to focus on important information they will be tested on at the end of the program. For example, the beginning of a lesson on patient assessment might state: “By the end of this lesson, the student will be able to…

a. Explain the A, B, C, D and E primary assessments.
b. List potential scene hazards to rule out before patient care can safely begin.
c. Identify and discuss the information that can be elicited about the patient’s chief complaint using the OPQRST questions.”9

• Stimulates recall of prior learning. Associating new information with prior knowledge can facilitate learning. It is easier for students to retain and recall information when it is associated with prior knowledge and experiences. Programs should begin with a review of what trainees should already know, then graduate to new or more complicated concepts and material. One way to stimulate recall of prior learning is with a pre-test that allows learners to focus on areas where they need improvement.

• Content and presentation. Content should be organized meaningfully in a logical sequence, and should typically be explained and then demonstrated. It makes little sense to explain to an EMT student the ABCs of patient assessment, then present the lesson out of order beginning with the elements of “C.” Doing so frustrates the learner and can cause confusion. Video segments that demonstrate processes can be very beneficial. Training officers should evaluate accompanying video for relevance to the content and applicability to the department’s standard operating procedures.

• Provides learning guidance. To help students retain new knowledge, additional guidance should be provided along with new information. Guidance can take the form of examples, mnemonics, graphical representations and analogies. Case studies have been used quite extensively in EMS to provide learning guidance. Some CBT systems use streaming video or audio clips to present patient assessment scenarios to students. The learner is then asked a series of questions about possible differential diagnoses and appropriate treatment methods. This builds critical thinking and decision-making skills among EMTs and can be directly related to patient assessment skills in the field.

• Elicits performance/practice. Learn-ers should be provided with ample time to practice their new skills or behaviors. Eliciting performance through the use of exercises and “pop” quizzes provides learners an opportunity to confirm their correct understanding of the material and aids in improving their retention of the material. One commercially available program includes interactive flash cards that give learners the opportunity to practice and memorize definitions.

• Assesses performance. Upon completion of instructional modules, students should be required to complete a final assessment (post-test). Typically, mastery of the material is indicated with a minimum passing score between 70%–80%. These assessments should be based on the learning objectives presented at the beginning of the lesson.

• Provides immediate feedback. Pre-tests, pop quizzes, interactive case studies, flash cards and other practice sessions should all provide immediate and specific feedback to learners regarding their performance. Practice exercises should accompany tutorials to aid in comprehension and retention of the material. Learners should be provided with formative feedback; that is, when the learner gives an incorrect answer to a question, the correct answer, along with a rationale for that answer, should be provided. Learners should also have the opportunity to review sections of the lesson following such exercises.

• Enhances retention and transfers to the job. The immediate goal of this training is to enable EMTs to gain the necessary knowledge to pass recertification. If a program cannot aid trainees in acquiring knowledge and using that knowledge to provide exceptional services to customers, it has no value to the organization. Effective training programs have a performance focus, incorporate design and media that facilitate knowledge retention, and transfer to the job. Although disliked by most students, repetition of learned concepts is one of the best ways to facilitate learning.

Conclusion

Quality service necessitates that providers be skilled in the art of their profession. Training is an essential element of providing quality customer service. For EMS agencies, this means ensuring that the department is providing its members with superior training that can be converted from the academic environment to practical application. CBT programs must be created with the understanding of how adults learn and the elements of good instructional design. Trainers and educators must allow for students’ input into the content of lessons and ensure they are relevant to the job.

CBT has proved to be a viable alternative to the traditional delivery methods of EMS instruction.3,10–13 It can provide a platform where learners can build on their past experiences to achieve their training goals; however, learning is not a given. It requires both experience and reflection. Personnel using CBT may not properly dedicate their time nor have the intrinsic motivation necessary to succeed in an environment of independent study. They may choose simply to get through the material as quickly as possible or be distracted from the material for more interesting activities. Learner choices such as these may be influenced by poor software design. Therefore, it is essential for training officers and educators to evaluate software programs for good motivational and design elements and have a method to continuously assess the effectiveness of training.

References

1. Brown KG. Using computers to deliver training. Which employees learn and why? Personnel Psychology 52(2):271–297, 2001.
2. Pollock C. Computer-aided instruction: A chip off the old book. Emergency 24(8):47–48, 1992.
3. Schmidt S, Gaston S. The effectiveness of computer-managed instruction versus traditional classroom lecture on achievement outcomes. Computers in Nursing 9(4):159–163, 1991.
4. Ericcson K, Krampe R, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychological Review 100(3):363–406, 1993.
5. Knowles M. The Modern Practice of Adult Education: Andragogy vs. Pedagogy. New York: Association Press, 1970.
6. Fidishun D. Andragogy and technology: Integrating adult learning theory as we teach with technology. Extending the Frontiers of Teaching and Learning: The Mid-South Instructional Technology Conference 2000. www.mtsu.edu/~itconf/proceed00/fidishun.htm.
7. Kruse K. Information is not instruction! February 2000. www.learningcircuits.org/2000/feb2000/Kruse.htm.
8. Gagne R. The Conditions of Learning (3rd Edition). New York: Rinehart and Winston, 1977.
9. Bledsoe B, Porter R, Shade B. Paramedic Emergency Care (3rd Ed.). Brady Prentice Hall: Upper Saddle River, NJ, 1997.
10. Belfry M, Winne P. A review of the effectiveness of computer-assisted instruction in nursing education. Computers in Nursing 6(2):77–85, 1988.
11. Fleschi D, Fleschi M, Soula G, Degoulet P. Evaluation of computer-assisted instruction methods. Pathogie Biologie 42(2):183–190, 1994.
12. Christenson J, Parrish K, Noseworthy R, et al. A comparison of multimedia and standard advanced cardiac life support learning. Academic Emergency Medicine 5(7):702–708, 1988.
13. Porter R. Efficacy of computer-assisted instruction in continuing education of paramedics. Ann Emerg Med 20(4):380–384, 1991.

EMT Training: The Phoenix Fire Department Way

Since taking on responsibility for EMS over three decades ago, the Phoenix (AZ) Fire Department has required all its firefighters to maintain a minimum of EMT-Basic certification. As with most agencies, the training requirements for EMTs are externally mandated by municipal codes, state statutes, national standards, etc. In order to balance the training needs of its members with budgetary constraints, the Phoenix Fire Department engaged in a 21st century solution: It replaced classroom lecture with computer-based instruction.

Phoenix’s CBT training program replaces the traditional classroom-based didactic instruction with a self-paced, in-house educational program. The program, which was custom-developed by members of the department’s EMS Section in consultation with the faculty of a local community college, was designed to meet or exceed the minimum requirements for training hours and content for EMT recertification as mandated by the Arizona Bureau of Emergency Medical Services. The goal of the program is to impart the knowledge, skills and abilities necessary for maintaining certification, while ensuring that the material can readily be applied to the field, and personnel can continue to provide the highest quality service to the department’s 1.5 million customers.

Each lesson in the program begins with an outline of learning objectives to be met, then uses a combination of narrated and non-narrated text, video presentations and interactive practice sessions to train the user in various subject matter. This training format allows personnel to access their training while on duty at the station, periodically checks trainee performance through assessments and provides immediate feedback to the user. System administrators are also able to monitor the progress of students throughout the course.

Recently, the department surveyed its members to determine their level of acceptance regarding the use of CBT for training, as well as their attitudes toward the current EMT recertification program. A number of important lessons were learned that are applicable to training officers who are considering implementing CBT in their organization.

First, although Phoenix EMTs were nearly universally comfortable with using computers, older employees tended to be somewhat uneasy with this format. Still, over 80% of the members surveyed indicated that they preferred the computer-based experience to the classroom. Implementation of voluntary computer classes designed to teach personnel how to use computer-based programs may be useful in raising the level of comfort with CBT. In addition, assistance should be available via a “computer help line” so personnel can contact someone who is in a position to answer their questions or to solve simple problems that might arise.

For the most part, users were positive regarding the EMT program’s design and content; however, the technical operation of the program was often reported to be problematic. Unintentional log-offs and lost assessment results were reported to be somewhat common. Losing one’s work can be a major demotivating factor. Addressing technical issues or, better yet, testing software prior to implementation can improve the acceptance of CBT, decrease frustration and improve motivation to use these systems.

Improving user flexibility was strongly recommended by the department’s members. Optimal training programs allow students to tailor their learning experience through the ability to self-pace; that is, to spend more time on subjects they need practice on while being able to test out of those they are proficient in. The more control students have with the computer-based training software, the more motivated they will be. To provide this control, software programs should offer options such as a main menu from which to choose a lesson or individual features, control of frame movement, or saving work to be completed later.

Finally, the first system installed by Phoenix was accessible only from department computers via the city Intranet. Members of busier companies expressed frustration with frequent interruptions from station routine, noise/activity around the workstation, emergency responses and the day-to-day activity of a firehouse. A quarter of all members surveyed requested a “work-from-home” option, and more than 76% of respondents indicated that they would indeed access the training program from home if this option were available.

The Phoenix Fire Department continues to seek improvements in all its training programs. The department has implemented many of the features requested by its members in its updated EMT training software, including Internet access, greater user flexibility and additional “challenge” sections for advanced learners. The best way to determine the acceptance of a computer-based training program (or any training program) is to elicit feedback from users. That feedback can then be used to make improvements to the program that will enhance the level of motivation and interest in this method of delivery, the overall quality of training, and, ultimately, service to the department’s customers.

—SS